Transcript No Slide Title

Microvascular
complications
Diabetes Outreach
(August 2011)
Microvascular complications
Learning outcomes
> understands the 3 main
microvascular complications of
diabetes
> can state the complication screening
required for microvascular disease
> is aware of broad management
principles.
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Microvascular disease
Microvascular disease refers to the disease of the
small blood vessels associated with thickening of
the basement membranes.
Consequences are:
eye disease
kidney disease
nerve damage
-
retinopathy
nephropathy
neuropathy
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What are the risk factors?
> hypertension
> dyslipidemia
> poor glycaemic control
> age and duration of diabetes
> family history
> smoking.
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Prevention, Prevention, Prevention
General principles:
> initial screening: depends on type of diabetes
and/or age of onset of diabetes
> ongoing screening (cycle of care) at least annual
screening (kidneys and nerves, second yearly
for eyes)
> early identification leads to early treatment.
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Diabetes and the eye
Short term issues
> high glucose causes the lens to swell and
distort which can affect vision temporarily
> blurry vision is common when newly
diagnosed and will settle down once blood
glucose levels are reduced.
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Diabetic retinopathy
> occurs as a result of microvascular disease of
the retina. It happens when elevated blood
glucose levels damage the fine blood vessels
of the retina
> if retinopathy is diagnosed early (eg before
vision loss) vision can be preserved
> there are different levels of retinopathy
depending on severity.
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BBBBB
Lens
Macula
Cornea
Optic
Nerve
Pupil
Iris
Retina
The eye
Bleeding blood
vessels
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Other eye problems
> Cataracts: an opaque or
cloudy lens can be made
worse by high blood
glucose.
> Glaucoma: fluid in the eye
builds up causing increased
pressure and damage to the
retina.
> Infections: if glucose levels
are high bacteria can grow.
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Screening and treatment for
retinopathy
> Review should occur at the time of diagnosis
and then at least every two years and more
frequently if problems exist.
> Inform the person that retinopathy can occur
without symptoms and so screening is
essential for early identification and treatment.
> If retinopathy is found laser is used to delay
and prevent further vision loss.
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Diabetes and the kidney
(nephropathy)
Nephropathy is a microvascular (small blood
vessels) complication related to high blood
glucose and high blood pressure.
> Glucose attaches to the small blood vessels
in the nephron causing damage.
> High blood pressure puts extra strain on the
blood vessels.
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Screening for nephropathy
> screen microalbuminuria annually by
> performing an albumin/creatine ratio
(mg/mmol) using early morning spot urine
> if first test is positive for microalbuminuria, 2
further samples need to be taken
> glomerular filtration rate (GFR) can also be
used as a measure of kidney function.
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Treatment of nephropathy
> maintain BP at less than 125/75
> ACE inhibitors even if BP normal
> screen urine regularly for infection as this may
make diabetic nephropathy worse
> adequate BGL control.
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Diabetes and the nerves
(neuropathy)
Neuropathy is a term used to describe nerve
damage. There are two main types of
neuropathy:
> Peripheral neuropathy – affects the
peripheral limbs of the body.
> Autonomic neuropathy – affects nerves
that supply the body structures that
regulate BP, heart rate, bowel and bladder
emptying and digestion.
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Peripheral neuropathy
> refers to nerve damage that affects the
peripheries
> nerve fibres are damaged and pain sensations
can be altered
> people with peripheral neuropathy are at high
risk of foot problems and require intensive foot
care education.
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Painful neuropathy
Image from Twigg and Sorensen, Med Today, 2010,11:3
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Peripheral neuropathy
The person needs to:
> have their feet checked regularly
> know if they have at risk feet
> have a foot protection plan appropriate to their
foot risk
> see a podiatrist if they have at risk feet
> see their doctor at any sign of infection.
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Autonomic neuropathy
> orthostatic
hypotension
> impaired gastric
emptying
(gastroparesis)
> diarrhoea
> erectile dysfunction
> silent MI’s
> hypo unawareness.
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Autonomic neuropathy may result in:
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orthostatic hypotension
impaired gastric emptying
diarrhoea
delayed/incomplete bladder emptying
erectile dysfunction and retrograde ejaculation in
males
reduced vaginal lubrication with arousal in women
loss of cardiac pain and ‘silent’ ischaemia or
infarction
sudden, unexpected cardio-respiratory arrest
especially under an anaesthetic or treatment with
respiratory depressant medication
difficulty recognising hypoglycaemia.
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Treatment & management
> cardiac – ECG, regular review
> postural hypotension – check for this and advise
to be careful when getting out of bed
> gastrointestinal – dietary advice
> bladder – encourage regular emptying and early
treatment of infections
> erectile dysfunction – counselling, medication,
prostheses
> hypo unawareness – adjustment of glycaemic
targets, and hypo action plan that includes
glucagon.
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Summary
> Microvascular complications can progress
without symptoms.
> All people with diabetes need regular screening
for microvascular complications.
> Achieving glycaemic, BP and lipid targets are
essential for preventing problems.
> People should be encouraged and supported to
stop smoking.
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References
> Diabetes Outreach (2009) Diabetes Manual,
Section 12, Long term complications.
> Kidney Health Australia (2007) Chronic Kidney
Disease (CKD) Management in General
practice. Available from www.kidney.org.au
> RACGP (2010) Diabetes Management in
General Practice. Available from
www.racgp.org.au/guidelines
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